Provider Demographics
NPI:1427376268
Name:2234 WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:2234 WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:619-871-3252
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-0008
Mailing Address - Country:US
Mailing Address - Phone:281-208-0000
Mailing Address - Fax:281-261-5017
Practice Address - Street 1:1110 TEXAS PARKWAY STE 600
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477
Practice Address - Country:US
Practice Address - Phone:281-208-0000
Practice Address - Fax:281-261-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04517261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center